hfs 3745 (n-4-99) il478-2471 - · pdf file23 inservice training & education 2,351 2,351...

FOR BHF USE IMPORTANT NOTICELL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION

THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY2015 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE

STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEDEPARTMENT OF HEALTHCARE AND FAMILY SERVICES ANY INFORMATION ON OR BEFORE THE DUE DATE WILLFINANCIAL AND STATISTICAL REPORT (COST REPORT) RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM

FOR LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.(FISCAL YEAR 2015)

I. IDPH License ID Number: 0014290 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Facility Name: THE CLAYBERG I have examined the contents of the accompanying report to the

Address: EAST MONROE STREET CUBA 61427 State of Illinois, for the period from 12/1/2014 to 11/30/2015Number City Zip Code and certify to the best of my knowledge and belief that the said contents

are true, accurate and complete statements in accordance withCounty: FULTON applicable instructions. Declaration of preparer (other than provider)

is based on all information of which preparer has any knowledge.Telephone Number: (309) 785-5012 Fax # (309) 785-5376

Intentional misrepresentation or falsification of any informationHFS ID Number: in this cost report may be punishable by fine and/or imprisonment.

Date of Initial License for Current Owners: 7/6/1969 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name) BERNITA KAY BITNERof Provider

VOLUNTARY,NON-PROFIT PROPRIETARY X GOVERNMENTAL (Title) ACTING ADMINISTRATORCharitable Corp. Individual StateTrust Partnership X County (Signed) Compilation Report is attached

IRS Exemption Code Corporation Other (Date)"Sub-S" Corp. Paid (Print Name JEFF MCPHERSONLimited Liability Co. Preparer and Title) PARTNERTrustOther (Firm Name GRAY HUNTER STENN LLP

& Address) 500 MAINE STREET, QUINCY, IL 62301

(Telephone) (217) 222-0304 Fax #(217) 222-1691 MAIL TO: BUREAU OF HEALTH FINANCE

In the event there are further questions about this report, please contact: ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICESName:DIANA KIEME Telephone Number: (309) 785-5012 201 S. Grand Avenue East

Email Address: Springfield, IL 62763-0001 Phone # (217) 782-1630SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015

III. STATISTICAL DATA D. How many bed-hold days during this year were paid by the Department?A. Licensure/certification level(s) of care; enter number of beds/bed days, 0 (Do not include bed-hold days in Section B.) (must agree with license). Date of change in licensed beds

E. List all services provided by your facility for non-patients. 1 2 3 4 (E.g., day care, "meals on wheels", outpatient therapy)

NONE Beds at Licensed Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? YES Report Period Level of Care Report Period Report Period

G. Do pages 3 & 4 include expenses for services or1 Skilled (SNF) 1 investments not directly related to patient care?2 Skilled Pediatric (SNF/PED) 2 YES NO X3 49 Intermediate (ICF) 49 17,885 34 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?5 Sheltered Care (SC) 5 YES NO X6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 49 TOTALS 49 17,885 7 Date started 7/6/1969

J. Was the facility purchased or leased after January 1, 1978?B. Census-For the entire report period. YES Date NO X

1 2 3 4 5 Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year?

Medicaid YES X NO If YES, enter numberRecipient Private Pay Other Total of beds certified 49 and days of care provided 1,307

8 SNF 1,307 1,307 8 9 SNF/PED 9 Medicare Intermediary NATIONAL GOVERNMENT SERVICES10 ICF 6,091 9,173 15,264 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH*

14 TOTALS 6,091 9,173 1,307 16,571 14 Is your fiscal year identical to your tax year? YES X NO

C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: 11/30/2015 Fiscal Year: 11/30/2015 bed days on line 7, column 4.) 92.65% * All facilities other than governmental must report on the accrual basis.

SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)

Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments TotalA. General Services 1 2 3 4 5 6 7 8 9 10

1 Dietary 211,205 8,422 4,594 224,221 224,221 224,221 12 Food Purchase 106,673 106,673 106,673 (6,757) 99,916 23 Housekeeping 165,271 10,258 175,529 175,529 175,529 34 Laundry 6,284 6,284 6,284 6,284 45 Heat and Other Utilities 75,242 75,242 75,242 (3,903) 71,339 56 Maintenance 70,901 7,970 42,368 121,239 121,239 121,239 67 Other (specify):* 7

8 TOTAL General Services 447,377 139,607 122,204 709,188 709,188 (10,660) 698,528 8B. Health Care and Programs

9 Medical Director 375 375 375 375 910 Nursing and Medical Records 1,039,118 118,569 1,157,687 1,157,687 1,157,687 10

10a Therapy 10a11 Activities 64,940 3,255 1,854 70,049 70,049 70,049 1112 Social Services 44,239 44,239 44,239 44,239 1213 CNA Training 1314 Program Transportation 1415 Other (specify):* 15

16 TOTAL Health Care and Programs 1,148,297 121,824 2,229 1,272,350 1,272,350 1,272,350 16C. General Administration

17 Administrative 72,061 1,471 73,532 73,532 73,532 1718 Directors Fees 1819 Professional Services 50,336 50,336 50,336 50,336 1920 Dues, Fees, Subscriptions & Promotions 12,691 12,691 12,691 (7,724) 4,967 2021 Clerical & General Office Expenses 59,092 13,384 8,299 80,775 80,775 80,775 2122 Employee Benefits & Payroll Taxes 751,001 751,001 751,001 751,001 2223 Inservice Training & Education 2,351 2,351 2,351 2,351 2324 Travel and Seminar 2425 Other Admin. Staff Transportation 362 362 362 362 2526 Insurance-Prop.Liab.Malpractice 28,522 28,522 28,522 28,522 2627 Other (specify):* 27

28 TOTAL General Administration 131,153 13,384 855,033 999,570 999,570 (7,724) 991,846 28TOTAL Operating Expense

29 (sum of lines 8, 16 & 28) 1,726,827 274,815 979,466 2,981,108 2,981,108 (18,384) 2,962,724 29*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000. SEE ACCOUNTANTS' COMPILATION REPORTNOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Facility Name & ID Number THE CLAYBERG #0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015

#V. COST CENTER EXPENSES (continued)

Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments TotalD. Ownership 1 2 3 4 5 6 7 8 9 10

30 Depreciation 46,933 46,933 46,933 46,933 3031 Amortization of Pre-Op. & Org. 3132 Interest 3233 Real Estate Taxes 3334 Rent-Facility & Grounds 3435 Rent-Equipment & Vehicles 3,087 3,087 3,087 3,087 3536 Other (specify):* 36

37 TOTAL Ownership 50,020 50,020 50,020 50,020 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3,130 3,130 3,130 3,130 3839 Ancillary Service Centers 68,295 7,125 201,198 276,618 276,618 276,618 3940 Barber and Beauty Shops 4041 Coffee and Gift Shops 4142 Provider Participation Fee 112,797 112,797 112,797 112,797 4243 Other (specify):* Lab & Radiology 3,292 3,292 3,292 3,292 43

44 TOTAL Special Cost Centers 68,295 7,125 320,417 395,837 395,837 395,837 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 1,795,122 281,940 1,349,903 3,426,965 3,426,965 (18,384) 3,408,581 45

*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.

In column 2 below, reference the line on which the particular cost was included. (See instructions.) 1 2 3

Refer- BHF USE B. If there are expenses experienced by the facility which do not appear in the NON-ALLOWABLE EXPENSES Amount ence ONLY general ledger, they should be entered below.(See instructions.)

1 Day Care $ $ 1 1 22 Other Care for Outpatients 2 Amount Reference3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 314 Non-Patient Meals (6,757) 2 4 32 Donated Goods-Attach Schedule* 325 Telephone, TV & Radio in Resident Rooms (3,903) 5 5 Amortization of Organization &6 Rented Facility Space 6 33 Pre-Operating Expense 337 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization8 Laundry for Non-Patients 8 34 Costs (Schedule VII) 349 Non-Straightline Depreciation 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ (18,384) 3713 Sales Tax 1314 Non-Care Related Interest 14 *These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions 15 licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation) 16 on these lines.17 Non-Care Related Fees 1718 Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 319 Entertainment 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions 20 reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance 21 (See instructions.) 1 2 3 422 Special Legal Fees & Legal Retainers 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. X $ 3824 Bad Debt 24 39 3925 Fund Raising, Advertising and Promotional (7,724) 20 25 40 Gift and Coffee Shops X 40

Income Taxes and Illinois Personal 41 Barber and Beauty Shops X 4126 Property Replacement Tax 26 42 Laboratory and Radiology X 4227 CNA Training for Non-Employees 27 43 Prescription Drugs X 4328 Yellow Page Advertising 28 44 4429 Other-Attach Schedule 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ (18,384) $ 30 46 Other-Attach Schedule 46

47 TOTAL (C): (sum of lines 38-46) $ 47BHF USE ONLY

48 49 50 51 52 SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5ATHE CLAYBERG

ID# 0014290Report Period Beginning: 12/1/2014

Ending: 11/30/2015Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 $ 12 23 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 32

HFS 3745 (N-4-99) IL478-2471

33 3334 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total 0 49

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary AFacility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSA. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

1 Dietary 0 0 0 0 0 0 0 0 0 0 0 0 12 Food Purchase (6,757) 0 0 0 0 0 0 0 0 0 0 (6,757) 23 Housekeeping 0 0 0 0 0 0 0 0 0 0 0 0 34 Laundry 0 0 0 0 0 0 0 0 0 0 0 0 45 Heat and Other Utilities (3,903) 0 0 0 0 0 0 0 0 0 0 (3,903) 56 Maintenance 0 0 0 0 0 0 0 0 0 0 0 0 67 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 78 TOTAL General Services (10,660) 0 0 0 0 0 0 0 0 0 0 (10,660) 8

B. Health Care and Programs9 Medical Director 0 0 0 0 0 0 0 0 0 0 0 0 9

10 Nursing and Medical Records 0 0 0 0 0 0 0 0 0 0 0 0 10 10a Therapy 0 0 0 0 0 0 0 0 0 0 0 0 10a11 Activities 0 0 0 0 0 0 0 0 0 0 0 0 1112 Social Services 0 0 0 0 0 0 0 0 0 0 0 0 1213 CNA Training 0 0 0 0 0 0 0 0 0 0 0 0 1314 Program Transportation 0 0 0 0 0 0 0 0 0 0 0 0 1415 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 15

16 TOTAL Health Care and Programs 0 0 0 0 0 0 0 0 0 0 0 0 16C. General Administration

17 Administrative 0 0 0 0 0 0 0 0 0 0 0 0 1718 Directors Fees 0 0 0 0 0 0 0 0 0 0 0 0 1819 Professional Services 0 0 0 0 0 0 0 0 0 0 0 0 1920 Fees, Subscriptions & Promotions (7,724) 0 0 0 0 0 0 0 0 0 0 (7,724) 2021 Clerical & General Office Expenses 0 0 0 0 0 0 0 0 0 0 0 0 2122 Employee Benefits & Payroll Taxes 0 0 0 0 0 0 0 0 0 0 0 0 2223 Inservice Training & Education 0 0 0 0 0 0 0 0 0 0 0 0 2324 Travel and Seminar 0 0 0 0 0 0 0 0 0 0 0 0 2425 Other Admin. Staff Transportation 0 0 0 0 0 0 0 0 0 0 0 0 2526 Insurance-Prop.Liab.Malpractice 0 0 0 0 0 0 0 0 0 0 0 0 2627 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 27

28 TOTAL General Administration (7,724) 0 0 0 0 0 0 0 0 0 0 (7,724) 28TOTAL Operating Expense

29 (sum of lines 8,16 & 28) (18,384) 0 0 0 0 0 0 0 0 0 0 (18,384) 29

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary BFacility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015

SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSD. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

30 Depreciation 0 0 0 0 0 0 0 0 0 0 0 0 3031 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 3132 Interest 0 0 0 0 0 0 0 0 0 0 0 0 3233 Real Estate Taxes 0 0 0 0 0 0 0 0 0 0 0 0 3334 Rent-Facility & Grounds 0 0 0 0 0 0 0 0 0 0 0 0 3435 Rent-Equipment & Vehicles 0 0 0 0 0 0 0 0 0 0 0 0 3536 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 36

37 TOTAL Ownership 0 0 0 0 0 0 0 0 0 0 0 0 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 0 0 0 0 0 0 0 0 0 0 0 0 3839 Ancillary Service Centers 0 0 0 0 0 0 0 0 0 0 0 0 3940 Barber and Beauty Shops 0 0 0 0 0 0 0 0 0 0 0 0 4041 Coffee and Gift Shops 0 0 0 0 0 0 0 0 0 0 0 0 4142 Provider Participation Fee 0 0 0 0 0 0 0 0 0 0 0 0 4243 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 43

44 TOTAL Special Cost Centers 0 0 0 0 0 0 0 0 0 0 0 0 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) (18,384) 0 0 0 0 0 0 0 0 0 0 (18,384) 45

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015

VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of BusinessFULTON COUNTY 100

B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,management fees, purchase of supplies, and so forth. X YES NO

If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance withthe instructions for determining costs as specified for this form.1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:

Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization

Ownership Organization Costs (7 minus 4)1 V 22 IMRF $ 200,942 FULTON COUNTY 100.00% $ 200,942 $ 12 V 22 FICA 133,927 FULTON COUNTY 100.00% 133,927 23 V 22 WORKERS' COMP INSURANCE 106,977 FULTON COUNTY 100.00% 106,977 34 V 22 UNEMPLOYMENT INSURANCE 2,126 FULTON COUNTY 100.00% 2,126 45 V 17 COMMITTEE PER DIEM EXPENSE 1,471 FULTON COUNTY 100.00% 1,471 56 V 26 PROPERTY & LIABILITY INSURAN 28,522 FULTON COUNTY 100.00% 28,522 67 V 78 V 89 V 9

10 V 1011 V 1112 V 1213 V 1314 Total $ 473,965 $ 473,965 $ * 14

* Total must agree with the amount recorded on line 34 of Schedule VI. SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES (continued)C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors. NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home must be listed on this schedule.

1 2 3 4 5 6 7 8Average Hours Per Work

Compensation Week Devoted to this Compensation Included Schedule V.Received Facility and % of Total in Costs for this Line &

Ownership From Other Work Week Reporting Period** ColumnName Title Function Interest Nursing Homes* Hours Percent Description Amount Reference

1 NONE $ 12 23 34 45 56 67 78 89 9

10 1011 1112 1213 TOTAL $ 13

* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.

** This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME,ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATION


HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization

A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO X City / State / Zip Code

Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( )

1 2 3 4 5 6 7 8 9Schedule V Unit of Allocation Number of Total Indirect Amount of Salary

Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility AllocationReference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6

1 $ $ $ 12 23 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 25


HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)

1 2 3 4 5 6 7 8 9 10Reporting

Monthly Maturity Interest PeriodName of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest

YES NO Required Note Original Balance (4 Digits) ExpenseA. Directly Facility Related Long-Term

1 NONE $ $ $ 12 23 34 45 5

Working Capital6 NONE 67 78 8

9 TOTAL Facility Related $ $ $ 9B. Non-Facility Related*

10 NONE 1011 1112 1213 13

14 TOTAL Non-Facility Related $ $ $ 14

15 TOTALS (line 9+line14) $ $ $ 15

16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ Line #

* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.(See instructions.) SEE ACCOUNTANTS' COMPILATION REPORT

** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.(See instructions.)

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued) B. Real Estate Taxes

Important, please see the next worksheet, "RE_Tax". The real estate tax 1. Real Estate Tax accrual used on 2014 report. statement and bill must accompany the cost report. $ 1

2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 2

3. Under or (over) accrual (line 2 minus line 1). $ 3

4. Real Estate Tax accrual used for 2015 report. (Detail and explain your calculation of this accrual on the lines below.) $ 4

5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C. (Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) $ 5

6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs classified as a real estate tax cost plus one-half of any remaining refund. TOTAL REFUND $ For Tax Year. (Attach a copy of the real estate tax appeal board's decision.) $ 6

7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 2010 8 FOR BHF USE ONLY2011 92012 10 13 FROM R. E. TAX STATEMENT FOR 2014 $ 132013 112014 12 14 PLUS APPEAL COST FROM LINE 5 $ 14

15 LESS REFUND FROM LINE 6 $ 15

16 AMOUNT TO USE FOR RATE CALCULATION $ 16

NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual of taxes from prior year.

2. If facility is a non-profit which pays real estate taxes, you must attach a denial of an application for real estate tax exemption unless the building is rented from a for-profit entity. This denial must be no more than four years old at the time the cost report is filed.


HFS 3745 (N-4-99) IL478-2471

2014 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME THE CLAYBERG COUNTY FULTON

FACILITY IDPH LICENSE NUMBER 0014290

CONTACT PERSON REGARDING THIS REPORT

TELEPHONE ( ) FAX #: ( )

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2014 on the lines provided below. Enter only the portion of thecost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursinghome property which is vacant, rented to other organizations, or used for purposes other than long term care must not beentered in Column D. Do not include cost for any period other than calendar year 2014.

(A) (B) (C) (D)Tax

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. $ $2. $ $3. $ $4. $ $5. $ $6. $ $7. $ $8. $ $9. $ $10. $ $

TOTALS $ $

B. Real Estate Tax Cost Allocations

HFS 3745 (N-4-99) IL478-2471

Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directlyused for nursing home services? YES NO

If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)

C. Tax Bills

Attach a copy of the original 2014 tax bills which were listed in Section A to this statement. Be sure to use the 2014tax bill which is normally paid during 2015.

PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax billdocumentation . Facilities located in Cook County are required to provide copies of their original second installment tax bill.

Page 10A

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 11Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 14,920 B. General Construction Type: Exterior BRICK Frame CONCRETE & STEEL Number of Stories 1

C. Does the Operating Entity? X (a) Own the Facility (b) Rent from a Related Organization. (c) Rent from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI. Those checking (c) may complete Schedule XI or Schedule XII-A. See instructions.)

D. Does the Operating Entity? X (a) Own the Equipment (b) Rent equipment from a Related Organization. (c) Rent equipment from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI-C. Those checking (c) may complete Schedule XI-C or Schedule XII-B. See instructions.)

E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds(such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, CNA training facilities, etc.)List entity name, type of business, square footage, and number of beds/units available (where applicable).NONE

F. Does this cost report reflect any organization or pre-operating costs which are being amortized? YES X NOIf so, please complete the following:

1. Total Amount Incurred: 2. Number of Years Over Which it is Being Amortized:

3. Current Period Amortization: 4. Dates Incurred:

Nature of Costs:(Attach a complete schedule detailing the total amount of organization and pre-operating costs.)

XI. OWNERSHIP COSTS: 1 2 3 4

A. Land. Use Square Feet Year Acquired Cost1 BUILDING SITE 217,800 1969 $ 5,000 12 23 TOTALS 217,800 $ 5,000 3


HFS 3745 (N-4-99) IL478-2471


XI. OWNERSHIP COSTS (continued) B. Building and Improvement Costs-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar.

1 2 3 4 5 6 7 8 9 FOR BHF USE ONLY Year Year Current Book Life Straight Line Accumulated

Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation4 49 1969 $ 271,336 $ 40 $ $ $ 271,336 45 1978 8,009 20 8,009 56 1979 52,096 30 52,096 67 78 8

Improvement Type**9 PATIO 1982 2,437 5 2,437 9

10 OFFICE REMODEL 1983 2,546 10 2,546 1011 DRAIN 1985 1,261 25 1,261 1112 ROOF 1986 1,200 15 1,200 1213 SHED, ROOF AND FLOOR TILE 1987 5,429 20 TO 25 5,429 1314 IDPA ADJUSTMENT 1989 1,806 90 20 90 1,625 1415 ROOF 1993 61,283 15 61,283 1516 ROAD REPAIR 1994 13,496 5 13,496 1617 STORAGE BUILDING ADDITION 1994 4,265 213 20 213 4,265 1718 STORAGE BUILDING ADDITION 1996 12,141 607 20 607 11,922 1819 LAUNDRY FACILITY 1997 15,274 764 20 764 14,224 1920 H/C SYSTEM 2000 4,564 228 20 228 3,461 2021 WALK, PATH 2001 4,177 278 15 278 3,945 2122 WALK, PATH 2002 1,357 90 15 90 1,214 2223 AVIARY 2002 4,740 316 15 316 4,240 2324 FLOORING 2004 634 10 634 2425 TWO A/C UNITS 2004 4,583 10 4,583 2526 FLOOR TILE 2005 290 11 25 11 125 2627 ELECTRICAL BOX 2005 141 6 25 6 61 2728 TWO METAL DOORS 2005 1,166 39 30 39 418 2829 WALL COVERINGS 2005 697 5 697 2930 EGRESS LIGHTS 2005 423 28 15 28 303 3031 SMOKE DETECTORS 2005 2,915 73 10 73 2,915 3132 NEW CORRIDOR WALL 2005 367 15 25 15 158 3233 KITCHEN FIRE SYSTEM 2005 2,877 82 35 82 870 3334 SIDEWALK 2005 802 53 15 53 561 3435 LABOR FOR BLDG IMPROVEMENT 2005 5,904 394 15 394 4,133 3536 WALL H/C UNITS 2005 2,729 205 10 205 2,729 36

*Total beds on this schedule must agree with page 2. See Page 12A, Line 70 for total**Improvement type must be detailed in order for the cost report to be considered complete SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12AFacility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015


1 3 4 5 6 7 8 9Year Current Book Life Straight Line Accumulated

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation37 HARBOR IN GARDEN 2005 $ 868 $ 35 25 $ 35 $ $ 353 3738 BASE BOARD HEATERS 2006 278 18 15 18 184 3839 FLOOR TILE 2006 640 26 25 26 250 3940 EAST EGRESS 2006 1,701 113 15 113 1,087 4041 EAST EGRESS SOIL 2006 390 13 30 13 125 4142 DOOR AND FRAME 2006 614 20 30 20 196 4243 WATER MAIN 2006 9,291 232 40 232 2,168 4344 WATER MAIN WALKWAY 2006 1,031 69 15 69 641 4445 DOOR LOCKS 2006 474 32 15 32 289 4546 LABOR FOR BLDG IMPROVEMENT 2006 4,098 273 15 273 2,595 4647 STEEL DOOR 2007 630 21 30 21 180 4748 SPRINKLER SYSTEM/CEILING UPGRADE 2007 151,553 10,103 15 10,103 84,196 4849 WIRING/ELECTRICAL OUTLETS 2007 635 32 20 32 262 4950 4 A/C UNITS 2007 1,668 167 10 167 1,376 5051 SENTRICON BAITING SYSTEM 2008 1,272 85 15 85 678 5152 PACKAGED UNIT AND DUCT WORK 2008 6,105 407 15 407 2,883 5253 ROOF WORK 2008 28,174 1,878 15 1,878 13,148 5354 GENERATOR REPAIR 2009 2,170 145 15 145 892 5455 FIRE PROTECTION - SPRINKLER SYSTEM 2009 25,825 1,722 15 1,722 10,330 5556 WALL PAPER 2010 6,294 420 15 420 2,413 5657 GARAGE DOOR 2012 848 85 10 85 318 5758 DINING DOOR 2012 3,092 103 30 103 387 5859 HEAT/COOL WALL AIR CONDITIONER 2012 1,912 191 10 191 717 5960 3 HEAT/COOL WALL AIR CONDITIONERS 2012 2,166 217 10 217 740 6061 FLOOR FINISH 2012 599 24 25 24 74 6162 OFFICE CARPET 2012 1,601 160 10 160 480 6263 LINEN CLOSET DOORS 2013 2,072 104 20 104 276 6364 JUICE BAR FOR DINING ROOM 2013 550 27 20 27 71 6465 4 THROUGH WALL H/C UNITS 2013 4,607 461 10 461 1,099 6566 DOOR ALARM AND OPENERS 2013 31,838 1,592 20 1,592 3,582 6667 ENTRANCE REPLACEMENT 2013 123,864 4,129 30 4,129 8,946 6768 FLOWER BOXES AND LANDSCAPING 2013 4,281 285 15 285 595 6869 WALL KIOSK 2014 8,254 825 10 825 1,307 6970 TOTAL (lines 4 thru 69) $ 920,340 $ 27,506 $ 27,506 $ $ 625,014 70

SEE ACCOUNTANTS' COMPILATION REPORT**Improvement type must be detailed in order for the cost report to be considered complete

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12BFacility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015


1 3 4 5 6 7 8 9Year Current Book Life Straight Line Accumulated

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 920,340 $ 27,506 $ 27,506 $ $ 625,014 12 FLOOR - DINING ROOM 2015 11,222 15 23 AMANA AIR CONDITIONER 2015 2,709 15 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 934,271 $ 27,506 $ 27,506 $ $ 625,014 34

SEE ACCOUNTANTS' COMPILATION REPORT**Improvement type must be detailed in order for the cost report to be considered complete

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 13Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015XI. OWNERSHIP COSTS (continued)

C. Equipment Costs-Excluding Transportation. (See instructions.) Category of 1 Current Book Straight Line 4 Component Accumulated Equipment Cost Depreciation 2 Depreciation 3 Adjustments Life 5 Depreciation 6

71 Purchased in Prior Years $ 170,193 $ 18,451 $ 18,451 $ 5 to 20 $ 112,331 7172 Current Year Purchases 21,355 976 976 3 to 10 976 7273 Fully Depreciated Assets 180,389 180,389 7374 7475 TOTALS $ 371,937 $ 19,427 $ 19,427 $ $ 293,696 75

D. Vehicle Costs. (See instructions.)*1 Model, Make Year 4 Current Book Straight Line 7 Life in Accumulated

Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Adjustments Years 8 Depreciation 976 Patient Transportation 2000 Chevrolet Bus 2000 $ 42,641 $ $ $ 5 $ 42,641 7677 Pickup, delivery, & plowing 2001 Ford truck w/ plow 2001 23,817 5 23,817 7778 7879 7980 TOTALS $ 66,458 $ $ $ $ 66,458 80

E. Summary of Care-Related Assets 1 2Reference Amount

81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 1,377,666 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 46,933 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 46,933 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 0 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 985,168 85

F. Depreciable Non-Care Assets Included in General Ledger. (See instructions.) G. Construction-in-Progress1 2 Current Book Accumulated

Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost86 $ $ $ 86 92 $ 9287 87 93 9388 88 94 9489 89 95 $ 9590 9091 TOTALS $ $ $ 91 * Vehicles used to transport residents to & from

day training must be recorded in XI-F, not XI-D.

SEE ACCOUNTANTS' COMPILATION REPORT ** This must agree with Schedule V line 30, column 8.

HFS 3745 (N-4-99) IL478-2471


XII. RENTAL COSTSA. Building and Fixed Equipment (See instructions.) 1. Name of Party Holding Lease: 2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4? If NO, see instructions. YES NO 00

001 2 3 4 5 6

Year Number Original Rental Total Years Total YearsConstructed of Beds Lease Date Amount of Lease Renewal Option*

Original 10. Effective dates of current rental agreement:3 Building: $ 3 Beginning4 Additions 4 Ending5 56 6 11. Rent to be paid in future years under the current7 TOTAL $ 7 rental agreement:

** 8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent This amount was calculated by dividing the total amount to be amortized by the length of the lease . 12. /2016 $

13. /2017 $ 9. Option to Buy: YES NO Terms: * 14. /2018 $

B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.) 15. Is Movable equipment rental included in building rental? YES X NO 16. Rental Amount for movable equipment: $ 3,087 Description: Copier $183.23 per month and dish washing machine $74 per month

(Attach a schedule detailing the breakdown of movable equipment)C. Vehicle Rental (See instructions.)

1 2 3 4Model Year Monthly Lease Rental Expense

Use and Make Payment for this Period * If there is an option to buy the building,17 $ $ 17 please provide complete details on attached18 18 schedule.19 1920 20 ** This amount plus any amortization of lease21 TOTAL $ $ 21 expense must agree with page 4, line 34.


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 15Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.)

A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facility program, attach a schedule listing the facility name, address and cost per CNA trained in that facility.)

1. HAVE YOU TRAINED CNAs YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION: DURING THIS REPORT PERIOD? X NO IN-HOUSE PROGRAM IN-HOUSE PROGRAM

IN OTHER FACILITY IN OTHER FACILITY If "yes", please complete the remainder of this schedule. If "no", provide an COMMUNITY COLLEGE HOURS PER CNA explanation as to why this training was not necessary. HOURS PER CNA

B. EXPENSES C. CONTRACTUAL INCOMEALLOCATION OF COSTS (d)

In the box below record the amount of income your1 2 3 4 facility received training CNAs from other facilities.

FacilityDrop-outs Completed Contract Total $

1 Community College Tuition $ $ $ $2 Books and Supplies D. NUMBER OF CNAs TRAINED3 Classroom Wages (a)4 Clinical Wages (b) COMPLETED5 In-House Trainer Wages (c) 1. From this facility6 Transportation 2. From other facilities (f)7 Contractual Payments DROP-OUTS8 CNA Competency Tests 1. From this facility9 TOTALS $ $ $ $ 2. From other facilities (f)

10 SUM OF line 9, col. 1 and 2 (e) $ TOTAL TRAINED

(a) Include wages paid during the classroom portion of training. Do not include fringe benefits. (e) The total amount of Drop-out and Completed Costs for(b) Include wages paid during the clinical portion of training. Do not include fringe benefits. your own CNAs must agree with Sch. V, line 13, col. 8.(c) For in-house training programs only. Do not include fringe benefits. (f) Attach a schedule of the facility names and addresses(d) Allocate based on if the CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs. your facility. Drop-out costs can only be for costs incurred by your own CNAs. SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471


XIV. SPECIAL SERVICES (Direct Cost) (See instructions.)1 2 3 4 5 6 7 8

Schedule V Staff Outside Practitioner SuppliesService Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost

Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)1 Licensed Occupational Therapist 39-3 hrs $ 1,595 $ 87,335 $ 1,595 $ 87,335 1

Licensed Speech and Language2 Development Therapist 39-3 hrs 522 31,280 522 31,280 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist 39-3 hrs 1,138 79,409 1,138 79,409 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy 39-3 prescrpts 6,215 3,174 6,215 3,174 9

Psychological Services (Evaluation and Diagnosis/

10 Behavior Modification) hrs 1011 Academic Education hrs 1112 Other (specify): STOCK DRUGS 39-2 7,125 7,125 12

13 Other (specify): RADIOLOGY 43-3 1,849 1,849 13

14 TOTAL $ 9,470 $ 203,047 $ 7,125 9,470 $ 210,172 14

NOTE: This schedule should include fees (other than consultant fees) paid to licensed practitioners. Consultant fees should be detailed on Schedule XVIII-B. Salaries of unlicensed practitioners, such as CNAs, who help with the above activities should not be listed on this schedule.


HFS 3745 (N-4-99) IL478-2471


XV. BALANCE SHEET - Unrestricted Operating Fund. As of 11/30/2015 (last day of reporting year) This report must be completed even if financial statements are attached.

1 2 After 1 2 After Operating Consolidation* Operating Consolidation*

A. Current Assets C. Current Liabilities1 Cash on Hand and in Banks $ 1,024,092 $ 1 26 Accounts Payable $ 46,426 $ 262 Cash-Patient Deposits 5,032 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 5,032 283 Patients (less allowance ) 281,546 3 29 Short-Term Notes Payable 294 Supply Inventory (priced at COST ) 3,675 4 30 Accrued Salaries Payable 79,205 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 6 31 (excluding real estate taxes) 317 Other Prepaid Expenses 7 32 Accrued Real Estate Taxes(Sch.IX-B) 328 Accounts Receivable (owners or related parties) 8 33 Accrued Interest Payable 339 Other(specify): PROPERTY TAX RECEIVABL 435,000 9 34 Deferred Compensation 93,236 34

TOTAL Current Assets 35 Federal and State Income Taxes 3510 (sum of lines 1 thru 9) $ 1,749,345 $ 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 DUE TO GENERAL FUND 62,500 3611 Long-Term Notes Receivable 11 37 DEFERRED PROPERTY TAXES 435,000 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 5,000 13 38 (sum of lines 26 thru 37) $ 721,399 $ 3814 Buildings, at Historical Cost 934,270 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 15 39 Long-Term Notes Payable 3916 Equipment, at Historical Cost 438,396 16 40 Mortgage Payable 4017 Accumulated Depreciation (book methods) (985,168) 17 41 Bonds Payable 4118 Deferred Charges 18 42 Deferred Compensation 4219 Organization & Pre-Operating Costs 19 Other Long-Term Liabilities(specify):

Accumulated Amortization - 43 4320 Organization & Pre-Operating Costs 20 44 4421 Restricted Funds 21 TOTAL Long-Term Liabilities22 Other Long-Term Assets (specify): 22 45 (sum of lines 39 thru 44) $ $ 4523 Other(specify): 23 TOTAL LIABILITIES

TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 721,399 $ 4624 (sum of lines 11 thru 23) $ 392,498 $ 24

47 TOTAL EQUITY(page 18, line 24) $ 1,420,444 $ 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 2,141,843 $ 25 48 (sum of lines 46 and 47) $ 2,141,843 $ 48

SEE ACCOUNTANTS' COMPILATION REPORT *(See instructions.)

HFS 3745 (N-4-99) IL478-2471


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ 1,484,369 12 Restatements (describe): 23 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 1,484,369 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) (537,890) 78 Aquisitions of Pooled Companies 89 Proceeds from Sale of Stock 9

10 Stock Options Exercised 1011 Contributions and Grants 1112 Expenditures for Specific Purposes 1213 Dividends Paid or Other Distributions to Owners ( ) 1314 Donated Property, Plant, and Equipment 1415 Other (describe) 1516 Other (describe) 1617 TOTAL Additions (deductions) (sum of lines 7-16) $ (537,890) 17

B. Transfers (Itemize):18 Transfer in from County IMRF Fund 200,942 1819 Transfer in from County FICA Fund 133,927 1920 Transfer in from County Insurance Fund 135,499 2021 Transfer in from County Unemployment Fund 2,126 2122 Transfer in from County General Fund 1,471 2223 TOTAL Transfers (sum of lines 18-22) $ 473,965 2324 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 1,420,444 24 *

* This must agree with page 17, line 47.


HFS 3745 (N-4-99) IL478-2471


XVII. INCOME STATEMENT (attach any explanatory footnotes necessary to reconcile this schedule to Schedules V and VI.) All required classifications of revenue and expense must be provided on this form, even if financial statements are attached. Note: This schedule should show gross revenue and expenses. Do not net revenue against expense.

1 2I. Revenue Amount II. Expenses Amount

A. Inpatient Care A. Operating Expenses1 Gross Revenue -- All Levels of Care $ 2,457,600 1 31 General Services 709,188 312 Discounts and Allowances for all Levels ( ) 2 32 Health Care 1,272,350 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 2,457,600 3 33 General Administration 999,570 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership 50,020 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 6 35 Special Cost Centers 283,040 357 Oxygen 7 36 Provider Participation Fee 112,797 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 379 Payments for Education 9 38 38

10 Other Government Grants 10 39 3911 CNA Training Reimbursements 1112 Gift and Coffee Shop 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 3,426,965 4013 Barber and Beauty Care 1314 Non-Patient Meals 6,757 14 41 Income before Income Taxes (line 30 minus line 40)** (537,890) 4115 Telephone, Television and Radio 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 1718 Sale of Supplies to Non-Patients 4,539 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ (537,890) 4319 Laboratory 1920 Radiology and X-Ray 20 III. Net Inpatient Revenue detailed by Payer Source21 Other Medical Services 21 44 Medicaid - Net Inpatient Revenue $ 1,356,810 4422 Laundry 22 45 Private Pay - Net Inpatient Revenue 597,683 4523 SUBTOTAL Other Operating Revenue (lines 9 thru 22)$ 11,296 23 46 Medicare - Net Inpatient Revenue 503,107 46

D. Non-Operating Revenue 47 Other-(specify) 4724 Contributions 24 48 Other-(specify) 4825 Interest and Other Investment Income*** 1,957 25 49 TOTAL Inpatient Care Revenue (This total must agree to Line 3) $ 2,457,600 4926 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 1,957 26

E. Other Revenue (specify):**** * This must agree with page 4, line 45, column 4.27 Settlement Income (Insurance, Legal, Etc.) 27 ** Does this agree with taxable income (loss) per Federal Income28 PROPERTY TAXES 418,222 28 Tax Return? N/A If not, please attach a reconciliation.

28a 28a *** See the instructions. If this total amount has not been offset against interest29 SUBTOTAL Other Revenue (lines 27, 28 and 28a) $ 418,222 29 expense on Schedule V, line 32, please include a detailed explanation.

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 2,889,075 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 20Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.) (This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES

1 2** 3 4 1 2 3# of Hrs. # of Hrs. Reporting Period Average Number Total Consultant Schedule VActually Paid and Total Salaries, Hourly of Hrs. Cost for Line &Worked Accrued Wages Wage Paid & Reporting Column

1 Director of Nursing 1,750 1,815 $ 45,522 $ 25.08 1 Accrued Period Reference2 Assistant Director of Nursing 2 35 Dietary Consultant 64 $ 4,594 353 Registered Nurses 5,648 5,836 161,654 27.70 3 36 Medical Director 3 375 364 Licensed Practical Nurses 14,155 15,077 329,299 21.84 4 37 Medical Records Consultant 375 CNAs & Orderlies 40,058 42,989 457,883 10.65 5 38 Nurse Consultant 386 CNA Trainees 6 39 Pharmacist Consultant 3,174 397 Licensed Therapist 7 40 Physical Therapy Consultant 1,138 79,409 408 Rehab/Therapy Aides 4,768 5,148 68,295 13.27 8 41 Occupational Therapy Consultant 1,595 87,335 419 Activity Director 1,481 1,486 24,429 16.44 9 42 Respiratory Therapy Consultant 42

10 Activity Assistants 3,160 3,515 40,511 11.53 10 43 Speech Therapy Consultant 522 31,280 4311 Social Service Workers 1,870 2,133 44,239 20.74 11 44 Activity Consultant 16 1,766 4412 Dietician 12 45 Social Service Consultant 4513 Food Service Supervisor 2,093 2,244 47,030 20.96 13 46 Other(specify) RADIOLOGY 1,849 4614 Head Cook 8,265 8,889 100,316 11.29 14 47 LAB 1,443 4715 Cook Helpers/Assistants 6,023 6,523 63,859 9.79 15 48 4816 Dishwashers 1617 Maintenance Workers 4,246 4,661 70,901 15.21 17 49 TOTAL (lines 35 - 48) 3,338 $ 211,225 4918 Housekeepers 14,331 15,517 165,271 10.65 1819 Laundry 1920 Administrator 2,000 1,820 72,061 39.59 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 2,345 2,289 59,092 25.82 23 Number Schedule V24 Clerical 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses $ 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 5129 Resident Services Coordinator 29 52 Certified Nurse Assistants/Aides 5230 Habilitation Aides (DD Homes) 3031 Medical Records 31 53 TOTAL (lines 50 - 52) $ 5332 Other Health CaCARE PLAN COO 1,632 1,837 44,760 24.37 3233 Other(specify) 3334 TOTAL (lines 1 - 33) 113,825 121,779 $ 1,795,122 * $ 14.74 34 SEE ACCOUNTANTS' COMPILATION REPORT

* This total must agree with page 4, column 1, line 45. ** See instructions.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 21Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountDEBORAH SIMAYTIS ADMINISTRATOR 0 $ 72,061 Workers' Compensation Insurance $ 106,977 IDPH License Fee $

Unemployment Compensation Insurance 2,126 Advertising: Employee Recruitment 326 FICA Taxes 133,927 Health Care Worker Background CheckEmployee Health Insurance 302,769 (Indicate # of checks performed )Employee Meals Patient Background Checks 65 650 Illinois Municipal Retirement Fund (IMRF)* 200,942 NON-ALLOWABLE ADVERTISING 7,699EMPLOYEE PHYSICALS 3,668 DUES AND SUBSCRIPTIONS 3,991

TOTAL (agree to Schedule V, line 17, col. 1) DRUG TESTING 492(List each licensed administrator separately.) $ 72,061 BONDING 100B. Administrative - Other

Less: Public Relations Expense ( ) Description Amount Non-allowable advertising (7,699) HEALTH COMMITTEE OF COUNTY BOARD EXPENSE $ 1,471 Yellow page advertising ( )

TOTAL (agree to Schedule V, $ 751,001 TOTAL (agree to Sch. V, $ 4,967 line 22, col.8) line 20, col. 8)

TOTAL (agree to Schedule V, line 17, col. 3) $ 1,471 E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**(Attach a copy of any management service agreement) to Owners or EmployeesC. Professional Services Description Amount Vendor/Payee Type Amount Description Line # AmountClifton Larsen Allen CPA $ 200 $ Out-of-State Travel $Frost Ruttenberg & Rothblatt Consulting 55Troy Jones Consulting IT Support 9,898S&B Technology Consultants IT Consulting 96 In-State TravelWescom Solutions IT Support 5,516A5.COM, L.L.C. IT Services 34Ability Medical Billing 2,729PointClick Care Accounting Consulting 2,606 Seminar ExpenseMiller, Hall & Triggs Legal 12,349Pro Data IT Services 2,811Templin Healthcare Accting Accounting Consulting 2,291See Page 24 11,751 Entertainment Expense ( )TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,(For legal fee disclosure, see page 39 of instructions) $ 50,336 TOTAL line 24, col. 8) $

* Attach copy of IMRF notifications **See instructions.SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471


XIX-H. SUPPORT SCHEDULE - DEFERRED MAINTENANCE COSTS (which have been included in Sch. V, line 6, col. 3). (See instructions.)

1 2 3 4 5 6 7 8 9 10 11 12 13Month & Year Amount of Expense Amortized Per Year

Improvement Improvement Total Cost UsefulType Was Made Life FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015

1 $ $ $ $ $ $ $ $ $ $23456789

1011121314151617181920 TOTALS $ $ $ $ $ $ $ $ $ $


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 23Facility Name & ID Number THE CLAYBERG # 0014290 Report Period Beginning: 12/1/2014 Ending: 11/30/2015XX. GENERAL INFORMATION:

(1) Are nursing employees (RN,LPN,NA) represented by a union? Yes (13) Have costs for all supplies and services which are of the type that can be billed tothe Department, in addition to the daily rate, been properly classified

(2) Are there any dues to nursing home associations included on the cost report? Yes in the Ancillary Section of Schedule V? YesIf YES, give association name and amount. IHCA $3,391

(14) Is a portion of the building used for any function other than long term care services for(3) Did the nursing home make political contributions or payments to a political the patient census listed on page 2, Section B? No. For example,

action organization? No If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attachbeen properly adjusted out of the cost report? a schedule which explains how all related costs were allocated to these functions.

(4) Does the bed capacity of the building differ from the number of beds licensed at the (15) Indicate the cost of employee meals that has been reclassified to employee benefitsend of the fiscal year? No If YES, what is the capacity? on Schedule V. $ 0 Has any meal income been offset against

related costs? Yes Indicate the amount. $ 6,757(5) Have you properly capitalized all major repairs and equipment purchases? Yes

What was the average life used for new equipment added during this period? 15 (16) Travel and Transportationa. Are there costs included for out-of-state travel? No

(6) Indicate the total amount of both disposable and non-disposable diaper expense If YES, attach a complete explanation.and the location of this expense on Sch. V. $ 9,770 Line 10 b. Do you have a separate contract with the Department to provide medical transportation for

residents? No If YES, please indicate the amount of income earned from such a(7) Have all costs reported on this form been determined using accounting procedures program during this reporting period. $

consistent with prior reports? Yes If NO, attach a complete explanation. c. What percent of all travel expense relates to transportation of nurses and patients? 0d. Have vehicle usage logs been maintained? Yes

(8) Are you presently operating under a sale and leaseback arrangement? No e. Are all vehicles stored at the nursing home during the night and all otherIf YES, give effective date of lease. times when not in use? Yes

f. Has the cost for commuting or other personal use of autos been adjusted(9) Are you presently operating under a sublease agreement? YES X NO out of the cost report? N/A

g. Does the facility transport residents to and from day training? No(10) Was this home previously operated by a related party (as is defined in the instructions for Indicate the amount of income earned from providing such

Schedule VII)? YES NO X If YES, please indicate name of the facility, transportation during this reporting period. $ N/AIDPH license number of this related party and the date the present owners took over.

(17) Has an audit been performed by an independent certified public accounting firm? YesFirm Name: Gray Hunter Stenn LLP

(11) Indicate the amount of the Provider Participation Fees paid and accrued to the Departmentduring this cost report period. $ 112,797 (18) Have all costs which do not relate to the provision of long term care been adjusted outThis amount is to be recorded on line 42 of Schedule V. out of Schedule V? Yes

(12) Are there any salary costs which have been allocated to more than one line on Schedule V (19) Has a schedule for the legal fees reported on the cost report been provided by the facility?for an individual employee? No If YES, attach an explanation of the allocation. See page 39 of the instructions for details. N/A

Attach invoices and a summary of services for all architect and appraisal fees.SEE ACCOUNTANTS' COMPILATION REPORT

HFS 3745 (N-4-99) IL478-2471

Page 4, line 43 Radiology $ 1,849 Laboratory 1,443

Page 19, line 28 Property Taxes $ 418,222

Page 21, XIX, C. Vendor/Payee Type AmountChaney Technology IT Services $ 962Diana Kieme Accounting Consulting 300Pathway Health Services Accounting Consulting 10,489

HFS 3745 (N-4-99) IL478-2471

hfs 3745 (n-4-99) il478-2471 - · pdf file23 inservice training & education 2,351 2,351...

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